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Approaches to Common Peripheral Nerves

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Approaches to Common Peripheral Nerves Bioness StimRouter™ PNS COMMON BEST PRACTICES Stay north – electrodes implanted at target site cephalad/upstream of pain or injury 1st Incision – minimum 5cm from target • 2nd Incision – exit for tunneling = patch placement, 1-2cm more than residual lead Patch placement – visualize and test patch placement before implant • Will patient need/have assistance for patch placement? • Will patch placement create friction or be uncomfortable with patient movement? • Will patient have to trim hair constantly in area of patch placement? • Donning site should be in same dermatome as targeted nerve if possible 02525_Bioness ©2017 COMMON BEST PRACTICES Consider the “triangle”: completing circuit with user patch CATHODE ‘Tighter’ Circuits = Higher Efficiency 1st INCISION CATHODE Good Better Better Best Best Note: triangle not applicable to all nerves. 02525_Bioness ©2017 PERIPHERAL NERVES ARM TRUNK LEG AXILLARY ILIONGUINAL SAPHENOUS SUPRASCAPULAR INTERCOSTAL TIBIAL ULNAR GENITOFEMORAL PERONEAL MEDIAN PUDENDAL LATERAL FEMORAL CUTANEOUS RADIAL ILIOHYPOGASTRIC SURAL CLUNEAL 02525_Bioness ©2017 AXILLARY NERVE Humerus 2nd Incision Target 1st Incision Quadrangular Space Teres Major Teres Minor Triceps 02525_Bioness ©2017 AXILLARY NERVE Pathology Post Stroke Shoulder Pain (PSSP) Relevant Quadrangular space (Humerus, Teres Major muscle, Teres Minor muscle, Long head of Anatomy triceps muscle) Posterior Circumflex artery. Positioning/App Patient prone with effected UE slightly abducted. 1st Incision over Posterior Deltoid, roach superiomedial insertion of lead towards quadrangular space. Lead is “L shaped”, with remainder of lead tunneled across middle of Deltoid muscle. Patch Cathode over receiving electrodes, Anode facing quadrangular space. Patch sits over Placement Posterior Deltoid Muscle. Confirmation of Motor response of glenohumeral approximation, slight external rotation from Teres muscle Target group, and possible mild shoulder retraction. Paresthesia in region of pain. Notes Subluxation will be highly prevalent in these patients. The Post C-flex artery is easily identified lateral to QS when viewing via US. Be sure to follow artery into QS to locate root of Axillary nerve before it bifurcates 02525_Bioness ©2017 SUPRASCAPULAR NERVE Target Supraspinatus 2nd Incision Suprascapular 1st Incision Notch Scapular Spine Infraspinatus 02525_Bioness ©2017 SSN ULTRASOUND IMAGE (SHORT AXIS) 02525_Bioness ©2017 SUPRASCAPULAR NERVE Pathology Adhesive Capsulitis, Hemiplegic shoulder pain. Relevant Spine of the Scapula, Infraspinatus fossa, Suprascapular notch. Supraspinatus muscle, Anatomy Suprascapular artery. Upper Trapezius muscle. Positioning/Appr Patient prone. 1st incision near medial border of Scapula, superior to spine of Scapula. Insert oach lead anteriolaterally towards lateral third of “boat”. Tunnel remainder of the lead towards upper medial shoulder/trapezius. Patch Placement Cathode over receiving electrodes, Anode facing “bow of boat”. Patch should not elicit motor in Upper Trapezius muscle and should not be placed over spine of Scapula. Confirmation of Paresthesia in painful region, per patient. Target Notes Suprascapular vs Axillary. Loop/Angle to ensure appropriate lengths. Consider that the lead spans the scapulothoracic joint. 02525_Bioness ©2017 ULNAR NERVE Target 2nd Incision Ulnar Groove 1st Incision Olecranon Medial Epicondyle 02525_Bioness ©2017 ULNAR NERVE ULTRASOUND IMAGE (SHORT AXIS) 02525_Bioness ©2017 ULNAR NERVE Pathology Trauma and/or Entrapment to nerve with Pain within Ulnar distribution Relevant Ulnar Groove/Cubital Tunnel, Olecrenon of Ulna, Medical Epicondyle of Humerus. Anatomy Positioning/Appr Patient can be sidelying, effected limb on top, for a posterior approach. 1st Incision proximal to oach Ulnar groove, proximodistal insertion of lead towards Ulnar groove. Lead is turned, with remainder of lead tunneled posterior, across the triceps/back of arm. Patch Cathode over receiving electrodes, Anode facing Ulnar groove. Patch sits over back of the Placement arm/triceps. Confirmation of Paresthesia to ulnar distribution, medial/ulnar side of forearm, and 5th digit and medial half of Target 4th digit. Notes Many patients will have undergone nerve transpositions, taking the ulnar nerve out of the ulnar groove, and placing it on the other side of the medical epicondyle. Patients can become uncomfortable in these positions for long periods of time. 02525_Bioness ©2017 SAPHENOUS NERVE Adductor Canal/ nd Femoral Vessels 2 Incision Semimebranous Sartorius 1st Incision Target Adductor Longus Vastus Medialis 02525_Bioness ©2017 SAPHENOUS NERVE Pathology Post-surgical trauma, Compression, and /or Viral infections Relevant Vastus Medialis muscle, Sartorious muscle, Semimembranosis muscle, Adductor Canal, Anatomy Adductor Longus muscle, Femoral vessels. Positioning/App Patient can be supine with LE externally rotated, exposing medial thigh. Incision is made roach proximal to target in Adductor canal. Insert lead inferiorly towards target. Remainder of lead is tunneled anteriolaterally towards front of thigh. Patch Cathode over receiving electrodes, Anode facing towards stimulation electrodes. Placement Confirmation of Paresthesia to painful distribution, per patient. Target Notes Ensure patch placement is anterior enough to remain out of friction between legs during ambulation. 02525_Bioness ©2017 ILIONGUINAL NERVE External Obliques 2nd Incision Transverse Abdominis Inguinal Ligament 1st Incision Pubic Bone Primary Target Secondary Target ASIS 02525_Bioness ©2017 ILIONGUINAL NERVE Pathology Trauma and/or Entrapment to nerve post child birth, hernias and hysterectomies. Relevant ASIS, Pubic bone, Inguinal Ligament and Canal, External Obliques muscle, Transverse Anatomy Abdominus muscle. Positioning/Appr Primary: Patient supine. 1st incision 1-2cm Alternative: Patient supine. 1st incision over oach inferiomedial to ASIS. Lead inserted inguinal canal/ring. Lead inserted superiolaterally inferiomedially towards lateral aspect of towards target near ASIS. Remainder of lead inguinal canal/ring. Remainder of lead tunneled superiorly. tunneled superior or medial depending on patch placement planning. Patch Cathode over receiving electrodes, Anode Cathode over receiving electrodes, Anode faces Placement faces inguinal stimulating electrodes. inguinal stimulating electrodes. Patch sits on Patch sits on lateral lower abdomen. lateral lower abdomen. Confirmation of Paresthesia in pelvic/genital distribution. Paresthesia in pelvic/genital distribution. Target Notes Pre-op patch placement will be necessary to ensure comfort and to address any pubic hair, garment issues, or extra adipose or hernias in area. Pre-op stimulation to determine tolerance is recommended in this sensitive region. 02525_Bioness ©2017 TIBIAL NERVE Tibialis Posterior 2nd Incision Flexor Digitorum Longus Flexor Hallucis Longus 1st Incision Target Medial Malleous 02525_Bioness ©2017 TIBIAL NERVE Pathology Tarsal Tunnel Syndrome, crush injuries, trauma. Relevant Tibialis posterior muscle, Flexor Digitorum muscle, Tibial Artery, Tibial Nerve, Flexor Anatomy Hallucis Longus muscle(TDANH), Medial Malleous Target: 3-5 cm superior of medial malleous, 2cm posterior to tibia Positioning/App Patient in a supine position and leg externally rotated for access to the medial ankle area or roach lying on their side. 1st incision will be superior of the target keeping lead in the medial compartment of the leg. Tunneling done in line with medial compartment keeping patch placement in mind. Patch Medial to the lower leg, next to the calf. Ensure patch placement is not stimulating the Placement gastrocnemius or Achilles tendon Confirmation of Paresthesia in the toes/painful region. Target Notes Mixed nerve. May need to loop or shelf lead layout to fit the 15cm lead distal to calf. Use spinal needle (EPIMED) to go thru crural fascia that is in lower leg. 02525_Bioness ©2017 PERONEAL (COMMON FIBULAR) NERVE Popliteal Fossa Fibular Neck 1st Incision Target Evertors 2nd Incision Tibialis Anterior 02525_Bioness ©2017 PERONEAL NERVE US IMAGE (SHORT AND LONG AXIS) 02525_Bioness ©2017 PERONEAL (COMMON FIBULAR) NERVE Pathology Trauma, Compression, Surgical Insult, and Athletic injuries. Relevant Fibular neck, Anterior Tibialis muscle, Evertor muscle group, Popliteal fossa. Anatomy Positioning/App Patient can be sidelying/hooklying, effected limb on top. Incision distal to target posterior to roach fibular neck. Insert lead superiorly towards target. Tunnel the remainder of the lead to a location where patch placement will be comfortable and not elicit motor activation. Patch Cathode over receiving electrodes, Anode facing towards stimulation electrodes. Placement Confirmation of Paresthesia to painful distribution, per patient. Target Notes Possible compression sleeve wear, due to impact and velocity of lower leg swing during gait. Clear presence of fixation hardware. 02525_Bioness ©2017 INTERCOSTAL NERVES 2nd Incision Sternum Spine Ribs Artery Target Intercostal Muscle 1st Incision 02525_Bioness ©2017 ICN ULTRASOUND IMAGE (SHORT AXIS) 02525_Bioness ©2017 INTERCOSTAL NERVES Pathology Post-surgical trauma, Compression, and /or Viral infections Relevant Ribs, Intercostal veins and arteries, Sternum and Spinal Column, Intercostal muscles Anatomy Positioning/Appr Patient can be sidelying or prone. Incision is made anteriolateral to target. Insert lead oach lateral to medial towards spine and towards target. Remainder of lead is tunneled between ribs or to make
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  • Special Areas in the Upper Limb and Their Borders the AXILLA O a PYRAMIDAL Space: Has a Flat Apex, 4 Walls, and a Base

    Special Areas in the Upper Limb and Their Borders the AXILLA O a PYRAMIDAL Space: Has a Flat Apex, 4 Walls, and a Base

    This document was created by Alex Yartsev ([email protected]); if I have used your data or images and forgot to reference you, please email me. Special Areas in the Upper Limb and their Borders THE AXILLA o A PYRAMIDAL space: has a flat apex, 4 walls, and a base. Superior border of scapula APEX First rib Clavicle Scapula POSTERIOR Subscapularis WALL Teres major Clavipectoral fascia LATERAL WALL Pectoralis minor ANTERIOR WALL Intertubercular groove of Pectoralis major the humerus; Thus also the tendon of Anterior axillary fold the long head of biceps MEDIAL WALL Chest wall and serratus anterior CONTENTS Axillary artery and its branches Axillary vein and its tributaries- brachial vein, basilic vein and thoracoepigastric vein Lymphatic vessels and axillary lymph nodes Cords and branches of the brachial plexus BOUNDARIES - Apex Medial wall – o Cervicoaxillary canal; passageway into the neck - Rib cage, chest wall – ribs 1-4 and o Bounded by the 1st rib, clavicle, and superior edge of the scapula the intercostal muscles o The vessel and nerve’s gateway into the arm - Serratus anterior - Base o Axillary fossa: fat, fascia, skin Lateral wall – - Anterior Wall– - Narrow wall; intertubercular groove o Pectoralis major, pectoralis minor, pectoral and clavipectoral fascia of the humerus o The inferior part is the anterior axillary fold - Posterior wall – o Scapula and subscapularis o Inferior border is the teres major and latissmus dorsi This document was created by Alex Yartsev ([email protected]); if I have used your data or images and forgot to reference you, please email me. The Medial Triangular Space, Lateral Triangular Space, and the Quadrangular Space These are gaps in the posterior wall of the axilla.